Recognition and treatment of post-dural puncture headache

Abstract

Post-dural puncture headache must be distinguished from tension headache, migraine, pre-eclampsia, meningitis, cortical vein thrombosis, intracerebral haemorrhage, subdural haematoma and intracranial tumour. A history of dural puncture may be absent. The headache varies in character but is relieved by lying down and by abdominal compression. Associated symptoms include neckache, nausea, vomiting, photophobia and diplopia. A neglected dural leak may result in convulsions or cranial subdural haematoma, coning and death. MRI assists in the differential diagnosis. The epidural needle may be resited at a higher interspace, which delays analgesia, risks a second dural puncture and may later cause high block; or an intrathecal catheter may be used. All patients require careful documentation, close monitoring, and top-ups administered by an anaesthetist. Bed rest is of no prophylactic value but, in the presence of headache, mobilization should be postponed pending definitive treatment. Hydration and analgesia provide only symptomatic relief. Epidural saline provides transient relief and some discomfort. Epidural blood patch relieves symptoms and stops CSF leak and is therefore definitive treatment, but often causes backache. Alternatives to blood, such as dextran 40, may be useful for Jehovah's Witnesses or if there is bacteraemia. The success of epidural blood patch depends on using about 20 ml of blood, injected no higher than the dural puncture about 48 hours after dural puncture, keeping the patient horizontal before and 2 hours after patching, and advising the patient not to bend or strain afterwards.